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Arterial Leg Ulcer Clinical Pathway

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Arterial Leg Ulcer Clinical Pathway Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Leg Ulcer Clinical Pathway 0-7 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) Refer patient to ‘Care Connects’ if no responsible practitioner currently involved with patient identified/informed Determine if MRP/NP is part of Family Health Team (FHT) or Community Health Centre (CHC) and consider additional supports available Medical/surgical history and co-morbidity management Risk factors include: Chronic renal disease considered within care plan Smoking Congestive heart failure Diabetes mellitus Impaired liver function Hyperlipidemia Use of systemic steroids, Hypertension immunosuppressive and chemotherapy Coronary artery disease >70 years of age History of cerebral vascular accident Age 50-69 years with history of diabetes (CVA) or smoking Low hemoglobin < 50 years with diabetes and one other Obesity atherosclerotic factor Poor nutrition History of vascular surgery or deep vein Decreased thyroid function thrombosis Psoriasis Bleeding disorders Autoimmune diseases Family history of arterial disease Medication reconciliation and their impact on wound healing Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, reviewed inhaled substances and nicotine replacement therapy) Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics) Vitamin and mineral supplementation Recent blood work and diagnostic test results reviewed and Determine bloodwork implications for wound healing considered Blood Sugar, if patient is Diabetic A1C, if patient is Diabetic Albumin CBC Kidney Function Colesterol level Any diagnostic tests done previously i.e: Vascular Segmental Studies, UltraSound Doppler Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 1 Patient’s nutritional status optimized Calculate Body Mass Index (BMI) Determine recent weight loss/gain Review blood work results Complete Mini Nutritional Assessment (MNA) If screening section results < 11 = complete assessment section If Assessment section results < 24 = Registered Dietician referral required Physical assessment performed Baseline blood pressure, pulse and respiration Baseline weight and height, BMI Wound and periwound assessment completed Complete: Measure and document size of wound using the following reliable tool: Arterial Wound Characteristics Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology 4 P’s of Arterial Ulcers Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance, are Pale wound base more painful than expected and have low to no exudate Punched-out appearance Results of LLA and ABPI/TBPI Assessment for infection Painful NERDS – Any 3 or more of the following indicate HIGH superficial infection Parched (low to no exudate) STONEES - Any 3 or more of the following indicate HIGH superficial infection in deep compartment (Require Urgent Medical Attention) Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722 Pain management considered and initiated Complete: Use 0 – 10 Numeric Pain Rating Scale Pain Red Flags Possible Infection Increase in pain level (new pain in patients with altered 0 1 2 3 4 5 6 7 8 9 10 sensation ) No Moderate Worst Pain Pain Possible Possible Arterial Involvement Pain Pain on walking (caused by intermittent claudication) Arterial pain is typically described as: Pain with elevation of lower limbs Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused Rest pain by intermittent claudication) Nocturnal pain Identify and document type of pain 1. Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin. Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 2 2. Nociceptive Pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Acute arterial occlusion is a life and limb-threatening situation Mild Opioids – e.g. Codeine which requires immediate emergency intervention especially if Strong Opioids – e.g. Morphine or Oxycodone there is sudden or severe pain Obtain MRP/NP orders for pharmaceutical treatments (opioids and non-opioids) Non-pharmacological pain control options Lower Limb Assessment Completed Bilateral lower leg assessment (LLA)completed Complete: Complete ABPI/TBPI Right ABPI/TBPI: Highest Right Ankle/Toe Pressure = If ABPI/TBPI completed within last 3 mths, results must be obtained Highest Brachial _______ If unable to obtain ABPI/TBPI, referral to medical imaging for Vascular Segmental Studies is Left ABPI/TBPI: Highest Left Ankle/Toe Pressure = recommended Highest Brachial _______ Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available. Repeat ABPI/TBPI assessment every 3 months if healing is not progressing Assess for Signs and symptoms of Peripheral Arterial Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial Disease (PAD): ankle) Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Non-healing wound Correct Outcome Based Pathway Confirmed Wound etiology and appropriate pathway established Confirm wound etiology Arterial ulcers are typically pale at base of wound, have ‘punched out’ appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TBPI Identify initial cause of wound Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 3 Results of lower leg assessment (LLA) Results of ABPI/TBPI Results of wound assessment Vascular Segmental Studies results If etiology is still unknown, referral is needed for wound Care lead or ET. Referral For Vascular Assessment Initiated/Completed Communication with MRP and/or Nurse Practioner to update on any significant changes in Peripheral Arterial Disease (PAD) (see guidelines for PAD) patient’s condition or the outcome of the assessment. Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available. ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Acute arterial occlusion is a life and limb-threatening situation which Pressure (TcPo2), Laser Doppler requires immediate emergency intervention Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies Signs and symptoms that may become severe may be associated with the following: Pale or blue skin ABPI <0.5 TBPI <0.64 Skin cold to the touch Urgent vascular surgical consult needed Sudden decrease in mobility No pulse where one was present prior to this Sudden and severe pain Wound Therapy Initiated Wound treatment plan determined in accordance to treatment Arrange for MRP/nurse practitioner orders as required to begin plan of care including goal (healable, maintenance or non-healable) agreeance to professional referral recommendations Identify any potential barriers to wound treatment plan Caution: USE DRY WOUND HEALING Utilize toolkit to determine wound cleansing, debridement and dressing selection 1. Keep eschar dry South West Region Wound Care Program 2. No occlusive dressings Wound Cleansing Table and Dressing Selection and Cleansing enablers 3. Do NOT debride CAWC Product Picker chart 4. Avoid tourniquet effect when securing dressings CAUTION: When Using Compression 5. If eschar becomes wet/boggy – URGENT referral to advanced wound care specialist is recommended Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial, but only if arterial supply is sufficient. Sufficient arterial supply should be objectively evidenced by diagnostic tests. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only. Compression therapy history documented: Previous compression garments Age of compression garments Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb 10 2107 4 Adherence Application and removal of compression in past Finances Reason compression treatment plan has changed if applicable Patient Discharge Planning Initiated For Patient Independence And Prevention Patient and caregiver concerns and goals integrated into the care Complete: plan and shared with care team Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Ensure all patient/caregiver
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